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Title and link for copyingDynamic deconstructive psychotherapy versus optimized community care
for borderline personality disorder co-occurring with alcohol use
disorders (a 30-month follow-up)http://findings.org.uk/PHP/dl.php?file=Gregory_RJ_1.abs&s=eb&sf=sfnosCLOSEComment/query to editorTweet

Gregory R.J., DeLucia-Deranja E., Mogle J.A.Journal of Nervous and Mental Disease: 2010, 198 (4), 292–298.Unable to obtain a copy by clicking title? Try asking the author for a reprint by adapting this prepared e-mail or by writing to Dr Gregory at gregoryr@upstate.edu.

Broad and sustained improvement possible for people with co-occurring
borderline personality and alcohol use disorders participating in
deconstructive psychotherapy.

Summary This US study evaluated the effectiveness of deconstructive
psychotherapy for people diagnosed with both borderline personality
disorder and active alcohol abuse or dependence. Very few studies have
examined specific treatments for this population, despite borderline
personality disorder being common amongst people with alcohol use
disorders. One UK study found that 53% of patients accessing alcohol services had a
form of personality disorder (based on 64 alcohol service patients,
randomly sampled from four urban centres).

Symptoms of borderline personality disorder can include “strong emotions,
rapid changes in feelings and moods, difficulties in controlling
certain impulses [including drinking and taking drugs], poor self
image, feelings of not fitting or belonging, and a deep sense of
emptiness and isolation”. Deconstructive psychotherapy involves a
participant working with a therapist to address ‘deficits’
(the term used in this paper) in different types of emotional
experiences. This includes helping the participant to explore and
change how they perceive interactions with others and their emotional
responses to events.

For the featured study a small sample of 30 participants had been
randomly assigned (half to each) to receive deconstructive
psychotherapy for 12 to 18 months or the best standard treatment
available in their community – ‘optimised community
care’, involving a combination of individual counselling,
medication management, self-help groups and case management. An earlier
article reported that in contrast to limited change during optimised
community care, during the first 12 months of deconstructive
psychotherapy there were significant decreases in heavy drinking days,
suicide attempts and self-harm, and institutional care, as well as
significant improvements in core symptoms of borderline personality
disorder, depression, and perceived social support. The current study
examined whether these in-treatment gains were sustained after
treatment ended.

Main findings

Up to 30 months after the trial started the authors tried to follow
up the 11 deconstructive psychotherapy patients who had completed at
least at least six months of treatment and the 13 allocated to
optimised community care who had stayed in the study for at least the
same period. By the final follow up just eight patients in each set
could be re-assessed.

Participants receiving deconstructive psychotherapy achieved greater
improvements overall than those receiving optimised community care.
Those who completed a follow-up assessment displayed large improvements
between baseline and 30 months on almost every symptom, behavioural,
and functional outcome. There were statistically significant
improvements over time in core symptoms of borderline personality
disorder, depression severity, suicide attempts and self-harm, heavy
drinking days, and perceived social support.

Compared to optimised community care, at 30 months deconstructive
psychotherapy had led to significantly greater improvements in symptoms
of borderline personality disorder and depression. Though heavy
drinking was virtually absent in the deconstructive psychotherapy
patients and still occurring on average twice a week among comparison
patients, this difference was not statistically significant so may have
occurred by chance. However, there was a significant difference in use
of recreational drugs, which by 30 months was on average no longer
occurring at all among deconstructive psychotherapy patients.

The authors’ conclusions

The findings from this study support the authors’ theory that
gains made during 12 months of deconstructive psychotherapy would be
sustained after treatment ended, and suggest that deconstructive
psychotherapy may be an effective treatment that can lead to broad and
sustained improvement for people with co-occurring borderline
personality and alcohol use disorders. Overall, deconstructive
psychotherapy participants received less group therapy than those
receiving optimised community care, but the same amount of individual
treatment, making the favourable outcomes associated with
deconstructive psychotherapy all the more notable.

commentary Personality disorders were once widely perceived to be
‘untreatable’, and on this basis many people were excluded
from treatment. This is starting to change, as more evidence comes to
light about how personality disorders may be responsive to clinical
interventions. Given that borderline personality disorder often occurs
alongside other mental health and substance use issues, health and
social care professionals providing psychological treatments to this
group are
advised to “monitor the effect of treatment on a broad range
of outcomes, including personal functioning, drug and alcohol use,
self-harm, depression and the symptoms of borderline personality
disorder“.

This study offers a small but significant contribution to the
evidence base on treatments for people with co-occurring borderline
personality disorders and problem drinking. Large and sustained gains
were observed in participants engaged with deconstructive
psychotherapy. However, by the final follow up only about half the
patients who started the study were reassessed, and the criterion for
choosing who was followed up included retention in treatment for the
deconstructive psychotherapy participants but not for the comparison
patients, who merely had to have remained in the study. These
considerations mean that the results seen at the 30-month follow-up in
these 16 patients may not be representative of how well the whole
sample did, nor the relative advantages of the treatments. Further
research is needed in larger samples to confirm the promising results
of the study.

Thanks for their comments on this entry in
draft to research author Robert Gregory of the SUNY Upstate Medical
University. Commentators bear no responsibility for the text including
the interpretations and any remaining errors.